Prazosin and headache reduction (5/28/20 newsletter)

May 31

We are pleased to have Carleton College students and alumni working with Concussion Alliance. Contributors this week:

Editors: Malayka Gormally.
Contributors: Malayka Gormally, Julian Szieff, Katie Taylor, and Zachary Touqan.

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Education

Webinar today, 4 pm EST

The webinar Helping Your Child Cope with Post-concussion Syndrome: Part 2 is today at 4 pm EST. Register to receive a Zoom invite from the Concussion Legacy Foundation, which is hosting the event.

Strategies for child concussion recovery

The CDC provides a handout concerning different actions that parents can take to help their children as they recover from concussions. While the handout offered a variety of different strategies for recovery, four key ideas were highlighted. The handout advises parents to avoid high-risk activities that could potentially put their child in danger of another head collision. Concussion patients are more likely to sustain subsequent head injuries shortly after their first concussion, and these head injuries are often more serious. Parents are also advised to help their child keep a positive attitude. While concussions are discouraging and disorienting, most concussion symptoms only last a couple of weeks, and parental support allows children to recover quickly.

The third recommendation to parents is to ensure that their child sleeps and rests for longer than usual during the concussion recovery. Finally, parents are advised to customize recovery based on the child’s symptoms. While these concepts are not unique to children, implementing proper concussion recovery tactics is uniquely challenging for parents of young concussion patients. As an example, a child may not announce that he or she has a headache. Instead, they will have issues with concentration and irritability. Learning the different signals of child concussion symptoms could help to implement an effective and safe concussion recovery.

Sports

The longer adolescents continued to play after a concussion, the worse the outcomes

A study found symptoms were worse, and recovery was slower in adolescents (aged 11-19 years) who continued to play after suffering a concussion. Researchers Daniel B. Charek, PhD, et al. found a dose-response to continuing to play after a concussion. They found that staying in the game longer than fifteen minutes (Long-Play) produced significantly worse outcomes than staying in the game less than fifteen minutes (Short-Play), and those athletes immediately removed from play (Removed) had the best outcomes. Average time to recovery (clearance to play) was 44 days for Long-Play, 28 days for Short-Play, and 19 days for Removed. Also, “Short-Play was 5.43 times more likely, and Long-Play 11.76 times more likely, to experience protracted recovery relative to Removed.”

In terms of symptom burden during the first 7 days after injury, Short-Play and Long-Play had “worse neurocognitive performance and higher symptom scores” than Removed. During days 8 through 30 after the injury, Short-Play and Long-Play had worse visual memory and visual-motor speed than Removed. In this same time period, verbal memory and reaction time were worse in Long-Play than Removed, but Short-Play was not affected. The study, which emphasized the need for immediate removal from play after a concussion, was published in The Journal of Head Trauma Rehabilitation.

Cannabis

The Covid-19 environment: what smokers and vapers need to keep in mind

An article published on CNN health spotlights the higher risk status of smokers, vapers, and other substance users in light of the current COVID-19 pandemic. According to the CDC, 13.7% of American adults are consistent tobacco users (as of 2018), and a Gallup poll notes that about 8% of Americans use some form of vaping regularly. Concussion Alliance covers this topic because of research into cannabis and CBD as it relates to traumatic brain injury and neuroinflammation.

Consistent smoking is damaging to the lungs, and "those who smoke tobacco or marijuana or who vape" may be hit particularly hard by Covid-19, according to the Director of the National Institute on Drug Abuse, Dr. Nora Volkow. Also, a study by Wei Liu et al., published in the Chinese Medical Journal, found that "The odds of a Covid-19 case becoming more severe -- and at the most extreme, leading to death -- were 14 times higher among people who had a history of smoking compared to those who did not smoke."

When it comes to vaping, we have less information and research to work with, but we have enough to make some informed decisions.

Both Harvard and Johns Hopkins professionals, among others, note that vaping is likely beneficial to adults as a complete substitute for smoking cigarettes and other tobacco products. That is not to say that vaping is safe, but that it may be better to think of vaping as the lesser of two evils compared to cigarettes, rather than a harmless alternative. It is easy to say that nicotine addicts should just stop smoking, but the harsh reality of the matter is that it isn't as easy as that. For people who are struggling with nicotine addiction while also wanting to minimize their risks in the current environment, it may be worth looking into alternatives that do not involve any form of inhalation; some alternative methods include nicotine patches and gum. A similar line of advice can be given to marijuana and CBD users who have choices, including edibles and other alternatives.

Diagnostics

ER patients at risk for concussion often do not receive proper evaluations or education

A recent study, published in the Annals of Emergency Medicine, evaluated 98 patients for their level of mild traumatic brain injury (mTBI) care in an academic level 1 trauma center. During the 4-week observational study, data were evaluated to see if potential mTBI patients received an mTBI evaluation, diagnosis, or discharge education. Researchers Rachel R Koval et al. found that there was no documentation of an mTBI evaluation for 50% of the “patients at high risk for mild traumatic brain injury.” Furthermore, of the 36 patients who received an mTBI diagnosis, only 15 received mTBI specific discharge information.

Patients were identified by a triage nurse based on symptomology questions during triage. (Was there a blunt force trauma? Was there a change in the level of consciousness as a result of the event?) Evaluation, education, and treatment data were pulled from clinician documentation. One concern with the data from this study is that evaluations and education could have occurred without documentation, but that would be another concerning issue.

Additionally concerning is that this study was conducted at a level 1 academic trauma center, a large extremely professional medical center. For smaller, less well-staffed medical centers, the number of patients receiving inappropriate evaluation or education could be even greater. Emergency room doctors are often the only providers that an mTBI patient will see. The evaluations, treatments, and information provided are essential point-of-care measures for appropriate care and rehabilitation. The lack of evaluation, diagnosis, and mTBI specific education is an important issue that ER departments should focus on to improve mTBI care and recovery.

Therapies

Prazosin may be effective in reducing chronic post-concussion headache frequency and severity

The official blog of the U.S. Department of Veterans Affairs is reporting remarkable preliminary results from a six-month clinical trial using prazosin to treat people with chronic post-concussion headaches. "After nine weeks of daily treatment with prazosin, the Veterans in Dr. Ruff's study reported an average reduction from 12 headaches a month down to five, and an average decrease in pain intensity from a nine on the 10-point scale to a four."

Prazosin is commonly used to treat PTSD and high blood pressure; it has the advantages of not being habit forming, having few side effects, and being available as a generic medication. This flyer has specifics about the study. The study may be closed, but individuals could inquire with their doctor if they want to try prazosin for chronic post-concussion headaches. The surmised method of action is that prazosin improves sleep and "may help clear inflammatory agents from the brain."

A related article, on the UW Medicine Memory & Brain Wellness Center website, notes that "prazosin directly increases glymphatic function," which helps clear the brain of toxic proteins. The original research on the glymphatic system was led by Dr. Jeff Iliff, PhD, who is now affiliated with the UW Medicine Memory & Brain Wellness Center. Dr. Iliff's studies found that "the glymphatic system fails in the aging brain and in the young brain after traumatic brain injury. Dr. Iliff's biography states that "The studies suggest that impairment of glymphatic function may be one factor that renders the aging brain vulnerable to protein aggregation and neurodegeneration and may link brain trauma early in life with the development of dementia in the decades that follow."

Veterans

Blast gauges aid US Military in addressing brain injuries

An article published by Business Insider, "The US military is putting sensors on body armor that can detect and measure exposure to potentially harmful blasts," discussed new blast sensors designed to be placed on the body armor of US service members. The system includes a sensor on the head, chest, and shoulder, and would be used to determine if the service members are in need of medical care. After an Iranian missile attack on US forces in Iraq this winter, over one hundred service members were diagnosed with mTBIs, even though initial reports did not indicate injuries. This lag in diagnosis was largely due to difficulties in recognizing mild traumatic brain injuries.

The new blast sensor system is still in a trial period that will last two and a half years. Still, the military is dedicated to ensuring that head impacts are more effectively diagnosed and addressed. These gauges read the blasts in pounds per square inch or PSI, reporting measurements in green, yellow, and red lights. A green light indicates one to four PSI, a yellow light indicates four to sixteen PSI, and a red light indicates more than sixteen PSI. Immediate feedback gives service members information about their own health, especially in high-stress environments where symptoms are more likely to be missed or brushed aside.

Part of the testing period includes data collection on the neurological impacts of each of the three lights. While a green light is better than a red light, it does not necessarily mean that the service member did not sustain a concussion. These sensors are currently in use in training centers, with plans of operational testing and use in as little as eighteen months. Our 11/7/19 newsletter covered a similar project.

Mental Health

MDMA assisted psychotherapy for PTSD could be available as soon as 2021

Although Concussion Alliance focuses on concussions (mTBI), patients sometimes also have PTSD; this comorbidity is especially common for veterans.

The non-profit Multidisciplinary Association for Psychedelic Studies (MAPS), released a press release highlighting new clinical trial data from their phase 3 trial investigating MDMA-assisted psychotherapy for PTSD. In this initial analysis of the first 60 patients, the data has a 90% chance of being statistically significant once the rest of the patients have finished their treatment. If trials continue to meet FDA standards, MDMA-assisted psychotherapy could be legal as soon as 2021.

In previous smaller phase 2 trials (20, 16, and 28 patients respectively), researchers found a significant therapeutic improvement when using MDMA and stated, “MDMA administration was overall safe in physically and psychiatrically healthy subjects and in a medical setting. Compared to other stimulants (particularly cocaine, amphetamine, and methamphetamine), addiction to MDMA is very rare.” This led the FDA to grant MDMA-assisted psychotherapy for PTSD a Breakthrough Therapy designation. MAPS researchers are optimistic that the treatment is scalable, especially given that approximately 70 new therapists were trained for this phase 3 trial.

As this is the first-ever Phase 3 trial of a psychedelic-assisted therapy, MAPS is hoping approval would be a “catalytic event that brings psychedelic medicine into the mainstream.” It is important to note that in this treatment, a small dose of MDMA is taken in a clinical setting that wears off by the end of the therapeutic session. While recreational use of MDMA is common, this approval as a therapy assisting agent would not change the legality of recreational use. Recreational use commonly “involves impure samples of MDMA, taking multiple other drugs, and often paying little attention to the physiological aspects of the drug experience. Nevertheless, even when one does look at recreational ecstasy, which is used by around 750,000 people every weekend in the UK, the rates of morbidity and mortality are low.”

Statistics

Major grant awarded to study the neurological risks associated with TBI and repetitive head injuries

The National Institutes of Health has awarded a $10 million, five-year grant for the study of the "impact of traumatic brain injury (TBI) and repetitive head impacts (RHI) on Alzheimer's Disease, Alzheimer's disease-related dementias and chronic traumatic encephalopathy (CTE) and resulting clinical syndromes," as well as Parkinson's Disease, according to a press release by the Boston University School of Medicine.

Dr. Ann McKee will lead a team of researchers from the VA Boston Healthcare System, the Boston University CTE Center, and the Icahn School of Medicine at Mount Sinai. The three institutions' brain banks will constitute "the largest cohort" of brains with TBI and RHI. An article in Mirage explains that the study will investigate the neurological risks associated with TBI and RHI. "Researchers are hopeful that when the five years are up, their work will lay the foundation for developing strategies to intervene, prevent, and treat trauma-related neurodegeneration diseases."

Women's Health

Female adolescents have “greater oculomotor and vestibular dysfunction” than males after a concussion

A study found that female adolescents had "greater oculomotor and vestibular dysfunction than male adolescents" when evaluated within three weeks of their injury at a sports medicine clinic. Researchers Margot Gray et al. found increased odds that female adolescents had an abnormal near point of convergence, an oculomotor function, compared to male patients. Female adolescents also had increased odds of abnormal tandem gait test performance, which is a test of vestibular function, compared to male patients. The study, which was a review of medical records, was published in Physical Therapy in Sport.

Physicians: when doing telemedicine, consider that domestic violence might be a factor for your patient

An article in Medscape details how physicians can identify domestic violence survivors over telemedicine appointments and suggests steps to take to assist patients. Carole Warshaw, MD, director of the National Center on Domestic Violence, Trauma, and Mental Health in Chicago, says that "'It is critical to "approach every clinical encounter knowing that domestic violence may be at play.'"

Culture

Pandemic-related increased incidence and severity of child abuse, a “top cause” of childhood TBI

Some news outlets are reporting an increase in the incidence and severity of child abuse during the pandemic. "Abuse is a top cause of TBI-related emergency room visits, hospitalizations, and deaths among children of all ages," according to concussion expert Dr. Elizabeth Sandel. An article in the York Daily Record reports that Pennsylvania "hospitals are treating more children with severe child abuse injuries," with a higher number of these cases requiring hospitalization. This increase in abuse correlates with the time frame of the Pennsylvania stay-at-home orders.

An article in neaToday, the publication of the National Education Association, reports a 45% reduction in "reported cases of child abuse and neglect in Montana." The article mentions a preprint study, Suffering in Silence: how COVID-19 School Closure Inhibit the Reporting of Child Maltreatment, by E. Jason Baron et al.. The study found that in Florida, the 27% reduction in child abuse reports is likely because schools are closed, and that "the number one source of reported maltreatment allegations" are school personnel.

Child abuse prevention strategies and tips for parenting under stress

Information on child abuse prevention is being offered to parents and educators. The Seattle School District is offering a tip sheet of helpful strategies for parents under stress, with links to helplines and the Crisis Text Line; the tip sheet was created by Seattle Children's Hospital and UW Medicine. Additional resources: tip sheets for stressed parents from the Child Welfare Information Gateway, and a 24/7 Parental Stress Line hosted by the nonprofit organization Parents Helping Parents.